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Death and Desirability: Retrospective Reporting of Unintended Pregnancy After a Child’s Death

  • Published:
Demography

Abstract

Social scientists have long debated how to best measure pregnancy intentions. The standard measure relies on mothers’ retrospective reports of their intentions at the time of conception. Because women have already given birth at the time of this report, the resulting children’s health—including their vital status—may influence their mothers’ responses. We hypothesize that women are less likely to report that deceased children were from unintended pregnancies, which may explain why some cross-sectional studies have shown that children from unintended pregnancies have higher survival, despite the fact that longitudinal studies have shown the opposite is true. Using Demographic and Health Survey data from 31 sub-Saharan African countries, we confirm that mothers are less likely to report that deceased children resulted from unintended pregnancies compared with surviving children. However, the opposite is true for unhealthy children: mothers more commonly report that unhealthy children were from unintended pregnancies compared with healthier children. The results suggest that mothers (1) revise their recall of intentions after the traumatic experience of child death and/or (2) alter their reports in the face-to-face interview. The study challenges the reliability of retrospective reports of pregnancy intentions in high-mortality settings and thus also our current knowledge of the levels and consequences of unintended pregnancies in these contexts.

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Notes

  1. In this article, we use the term “unintended” to denote pregnancies that women report were mistimed or unwanted. In supplemental analyses, we differentiate between these pregnancies to ensure that key study findings are consistent for both types of unintended pregnancies.

  2. This approach is used in domestic (e.g., National Survey of Families and Households, National Survey of Family Growth, National Longitudinal Survey of Youth) and international (e.g., Demographic and Health Survey) surveys and, as a result, is the basis of the vast majority of our knowledge on the levels, causes, and consequences of unintended pregnancies worldwide.

  3. Of course, the concern with ex post revision of retrospective reports is not limited to studies on unintended pregnancy; it has been noted in reporting issues as diverse as self-rated health (Vuolo et al. 2014), stress-related coping behaviors (Belli 1998), and alcohol consumption (Searles et al. 2002).

  4. In high-income countries, poor, less-educated women face a disproportionately higher risk of experiencing unintended pregnancy compared with their socioeconomic advantaged peers, which then puts these women at further risk of poverty (Mosher et al. 2012). Thus, in high-income countries like the United States, socioeconomic inequalities are a key part of the link between unintended pregnancy and child well-being, both as a confounder and as a mechanism. Although widespread poverty and the lack of medical infrastructure contribute to the overall higher rate of unintended fertility in low- versus high-income countries (Sedgh et al. 2014), little evidence suggests a socioeconomic gradient in risk of unintended fertility among sub-Saharan African women (Ikamari et al. 2013), which is why we do not include it in our conceptual model here. However, we do account for socioeconomic status in all multivariate models.

  5. Singh and colleagues (2012) reported bivariate findings, based on their full sample, that Indian children from unintended pregnancies have lower mortality compared with their intended peers. Despite these descriptive findings from the full sample, both studies reported mother-level fixed-effects models that show unintended pregnancy is linked to higher mortality. The fixed-effects models use a subsample of mothers with multiple children and variation in pregnancy intentionality to compare the outcomes of siblings while holding all time-invariant maternal factors constant. That is, among the subsample of women with variation in pregnancy intentionality across children, children from unintended pregnancies have higher mortality compared with siblings from intended pregnancies. Family fixed-effects models typically reduce the size and strength of findings, given that unobserved factors are accounted for, standard errors are inflated, and unintendedness spills over to disadvantage all children (Barber and East 2011). However, the models also produce results in the opposite direction. The most plausible explanation for the reversal in direction is the nonrepresentative nature of the fixed-effects sample and the fact that birth order—which is highly associated with unintended pregnancy and child death and varies between siblings—may be driving the finding. The authors of both studies have called for additional research to better clarify the association between unintended pregnancy and child mortality.

  6. The estimates calculated by Sedgh and colleagues (2014) pertain to all unintended pregnancies among women aged 15–44, including pregnancies that ended in a live birth, an abortion, or a miscarriage. For the sub-Saharan Africa region, the study relies on Demographic and Health Survey data to calculate the percentage of unintended pregnancies, leaving open the possibility that these estimations are biased by the retrospective nature of women’s reports.

  7. To test the robustness of our results to sample restrictions, we conducted supplementary analyses on two additional samples. First, rather than focusing on the most recently born child in the past five years, we randomly selected one child from each mother. Second, because birth order is very closely correlated with pregnancy intentions, child survival, and child health, in a second set of parity-restricted estimates, we re-estimated the models focusing only on firstborn children (born in the past five years). Each additional set of models produced estimates that are similar in size and statistical significance as those reported in the tables.

  8. Additional bivariate results (not shown here) confirm that whereas 24 % of deceased children are reported as resulting from an unintended pregnancy, 28 % of living children are reported as unintended.

  9. More information on the survey is available online (www.dhsprogram.com).

  10. The logistic regression models predicted whether the child was declared as unintended while in utero but retrospectively recalled as intended (= 1) versus any other configuration of reports (= 0) (reference group). In all models, we controlled for the relevant covariates available in the data: mothers’ age, sibship size, household wealth, household size, and mothers’ education. All models also accounted for the clustered design of the survey.

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Acknowledgments

The authors gratefully acknowledge use of the services and facilities of the Population Studies Center at the University of Michigan, funded by NICHD Center Grant R24 HD041028 and the support of an NICHD training grant to the Population Studies Center at the University of Michigan (T32 HD007339) during the preparation of this manuscript. The manuscript benefited greatly from feedback Sara Yeatman and Jenny Trinitapoli graciously provided. We also thank three anonymous reviewers and the Editor for helping us further improve the manuscript. The paper also benefited from valuable feedback from participants in Session 149 (Fertility: Childbearing Decisions, Regrets, and Reassessments) at the 2015 American Sociological Association, UCLA California Center for Population Research Seminar series, and the UC-Irvine Center for Demographic and Social Analysis speaker series.

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Authors and Affiliations

  1. Department of Sociology, University of Southern California, 851 Downey Way, HSH, Office 309, Los Angeles, CA, 90089, USA

    Emily Smith-Greenaway

  2. Department of Sociology, Purdue University, West Lafayette, IN, USA

    Christie Sennott

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  1. Emily Smith-Greenaway
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Correspondence to Emily Smith-Greenaway.

Appendix

Appendix

Table 5 List of countries, year of DHS survey, and corresponding sample size of children younger than five years old
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Table 6 Descriptive statistics for children from 31 sub-Saharan African countries, by analytic sample and mother’s retrospective report of whether the child resulted from an unintended vs. intended pregnancy
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Table 7 Fixed-effects multinomial logistic regression model results of the relationship between sub-Saharan African children’s outcomes (vital status, recent illness, and stunting) and mother’s retrospective reports of whether the child resulted from a mistimed or unwanted pregnancy versus an intended pregnancy
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Smith-Greenaway, E., Sennott, C. Death and Desirability: Retrospective Reporting of Unintended Pregnancy After a Child’s Death. Demography 53, 805–834 (2016). https://doi.org/10.1007/s13524-016-0475-9

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  • DOI: https://doi.org/10.1007/s13524-016-0475-9

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